We taught you what cardiac chest pain looked like, right? You remember.
We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.
All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.
What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.
Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.
It gets worse:
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After my post/rant about the overuse and misuse of the DCAP BTLS TIC acronym in EMS education, I was asked the question, ” Well, are there any acronyms that you do find useful?” And the answer is an
emphatic yes. Some acronyms make for useful mnemonic devices to help us recall needed information in stressful situations. Despite my strongly worded warning about the use of acronyms, I think there are several good ones that have valid clinical uses.
For sure one of the more useful acronyms I’ve learned is OPQRST. I learned it back in EMT school in 1989 and I’ve been using it ever since. I can’t imagine how many times I’ve gone through these letters in my mind while meandering through a subjective assessment with a patient.
This is an acronym that has stood the test of time, which is saying a lot in the word of emergency medicine. Considering everything that has come and gone in the last three decades of EMS evolution, the most remarkable thing we can say about OPQRST is that it has endured.
Today lets dive a little deeper into the nature of OPQRST questioning. What does OPQRST mean? When should we use it? What kinds of questions should you be asking to get the information we’re looking for and where does the OPQRST standard fall short of providing us with a complete picture of a patients pain.
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How bad does it hurt? I’m willing to go out on a limb and say that this is, quite possibly, the most common question we ask in EMS. And it can be a difficult question to answer. How bad compared to what? How do we reconcile the patient with significant pain who winces and says it only hurts a little. Or what about the
patient who is relaxed and seemingly comfortable while reporting the worst pain they have ever felt?
Not everyone feels pain the same way. Some patients feel pain more than others. And, perhaps even more significant, some patients fear pain more than others. What’s a clinician to do?
You and I aren’t the first ones to wrestle with this question. Medicine has devised a multitude of way to ask patients how much pain they are experiencing. We’ve even gone lengths to try to assess which ones are comparatively more accurate. From numeric rating scales to verbal rating scales to visual analogue scales. (No, I didn’t make that up.)
If you prefer to know who’s scale you’re using you can try the Wong-Baker faces scale, the McGill scale or even the Walid-Robinson pain index. (The patient needs to be taking opiates to use that last one.)
The truth is, we may just be wasting or time trying to develop more sophisticated and accurate ways of asking this question. With rare exceptions, prehospital folk tend to use the standard numeric rating scale, A.K.A. the 1-10 scale. It’s simple, it’s relatively fast and it doesn’t require us to carry around cards with faces on them or lists of questions.
I’ve always used the numeric scale and I’ve found it to be simple and useful but it has its pitfalls. You need to be careful how you ask the question. You also need to have a few back-up questions ready to help clarify the answer. Here are some of the questions I ask when I’m assessing pain severity.
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Take a moment to increase your pain vocabulary
It’s been said that the Inuit have over a hundred words to describe snow. Linguists use the number to explain something significant about how we see the world. The Inuit and Eskimo encounter snow much more frequently than the average Spanish or English speaker, therefore they would describe it with more words. But it also gives insight into our life experiences. When an Inuit sees snow, he sees more than you or I do. Same snow, more meaning.
And so it is with medicine and pain. We see a bunch more pain than the average everyday Joe. We learn to evaluate pain more deeply and we understand more about it. It stands to reason that we would have more words to describe pain.
Most of us are pretty efficient at evaluating pain. We push, we prod, we ask our OPQRST questions and we get an idea about what’s going on. But sometimes we come up short when it comes to describing what we’ve found. When it’s time to hand off to another medical provider we can have those moments when our palette of pain words run dry.
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